Audit

Mat-Su Regional Medical Center

Physical Environment & Infection Control Rounds - OR Areas 2013

EC.04.01.01.14.a

Surveyed By:

Surveyed By:

PATIENT SAFETY MANAGEMENT

Are corridors kept clear to allow adequate space for:

A) Patients, visitors and staff to walk safely?

B) Carts, wheelchairs, equipment and beds to pass with

C) Are floors clear and slip-resistant finishes in place?

Are medication and sharps secured and locked:

A) Are medication rooms and anesthesia carts locked when not attended?

B) Are needles and syringes locked when unattended?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

FIRE SAFETY MANAGEMENT

Are the means of egress corridors/exit doors:

A) Clearly and correctly marked for EXIT, including when fire doors are closed?

B) Are lights in exit signs functional?

C) Clear of any obstructions/equipment?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are all fire extinguishers:

A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?

B) Inspection tags current? (monthly and annual)

C) Safety seals intact and in place?

D) Accessible, with three foot clearance in all directions?

E) Within seventy five feet in any direction in the area?

F) Are there CO2 fire extinguisher in place for use in operating rooms?

G)Is there a roll of orange masking tape in the extinguisher box? (main corridors only)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are the fire alarm pull stations:

A) Accessible, with three foot clearance in all directions?

B) In good condition, free from tampering and glass bar in place where applicable?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are combustible materials: cardboard, boxes, paper, linen, wastes)

A) Stored in proper containers? (32 gallons or less)

B) Kept to a minimum for daily use in department?

C) Properly labeled and identified?

D) Are alcohol-based hand rubs properly mounted from electrical devices? (6 inches from device)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Compressed gases and trash/linen chutes:

A) Are there less than 12 E-tanks (300 cu ft, oxygen) stored in the smoke compartment?

B) Where compressed gas storage exceeds 300 cu ft, is there a designated, protected storage room?

C) Full and empty O2 cylinders in storage are segregated? (Full & Empty)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Fire Building Systems, components and Safety Practices:

A) Are all doors free from being propped, wedged or held open in any way?

B) Are all doorways clear to close properly?

C) Do patient room doors latch when closed?

D) Do fire and stairwell doors latch positively and maintain closure?

E) Do door coordinators function properly where installed?

F) Are all doors physically in good condition to prevent the spread of smoke or fire?

G) Are rooms used as patient sleeping rooms free of deadbolt locks?

H) Is the area free from any evidence of smoking in the area?

I) Are furnishing and decorations fire-rated?

J) Is there at least 18 inches of clearance between storage and sprinkler heads?

K) Are escutcheons in place on sprinkler heads and are they clean and free of debris?

L) Do patient privacy curtains have at least an 18 inches mesh top?

M) Is the area free from portable heaters and heating devices? (No heaters in the hospital per CHS)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

SAFETY MANAGEMENT

Are the floors in hallways:

A) In good physical condition?

B) Clean and dry?

C) Free from trip/fall hazards?

D) Wet floor signs used properly?

E) Carpet free of wrinkles or tears?

F) Free from obstruction? ( wires/cords etc.)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are the walls:

A) Painted and in good physical condition? (Free of holes or water damage)

B) Free from exposed wiring of any kind?

C) Are electrical covers/plates in place and in good condition?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are ceiling tiles:

A) In place and in good condition?

B) Free of dirt, mold, dust and stains?

C) Free from evidence of water stains?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

INFECTION CONTROL MANAGEMENT

Infection Control Practices:

A) Are all sharps containers less than 2/3 full?

B) Is clean linen kept covered?

C) Is the clean linen physically and clearly separated from the dirty linen?

D) Are all medications dated and labeled?

E) Any outdated medication/supplies found?

F) Are refrigerators labeled to identify Patient,Staff and Medication use?

G) Are all foods dated and labeled?

H) Are current temperature logs in place and readily available?

I) Are cardboard boxes off the floor, with no corrugated shipping containers present?

J) Is there evidence of BLOOD BORNE PATHOGEN PRECAUTION procedures in place? (gloves, masks, gowns, separation of waste, etc.)

K) Is personal protective equipment readily available for use?

L) Are the cabinets under the sinks free from storage of clean supplies/equipment?

M) Are all sharps storage areas kept locked at all times?

N) Have all product recalls been corrected by department?

O) Are floors, fixtures and equipment in clean condition?

P) Are patient rooms and bathrooms clean and suitable for patient care?

Q) Are emergency showers and eye washes tested?

R) Are current temperature logs in place and readily available on all blanket warmers? Are temperatures within range for blanket warmers (<130) and fluid warmers (<110)?

S) Are carts and transport equipment free of dirt, rust and corrosion?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

HAZARDOUS MATERIAL AND WASTE MANAGEMENT

Hazardous chemicals used in the area:

A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)

B) Labeled correctly?

C) Disposed of correctly? (Are there procedures for disposal?)

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

MSDS Manual in the Area:

A) Have the department inventory (online) been updated within the past 12 months?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Medical Waste:

A) Stored in properly labeled bags and containers?

B) Properly stored and disposed of?

C) Stored and segregated appropriately?

D) Are bio-hazardous waste bulk storage areas secured, except to essential personnel?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

MEDICAL EQUIPMENT MANAGEMENT

A) Are the inspection tags current with date of next inspection?

B) Is clean equipment identified and stored properly?

C) Are crash carts or carts with sharps and meds locked?

E) Are crash cart logs documented consistently?

F) Are medical equipment consumables (defib, pads, etc.) within expiration dates?

G) List two (2) equipment inventory tag numbers and verify that equipment information is correct and inspections are current.

H) Are daily air removal tests (DART) performed on sterilizers and do records show compliant test results?

I) Are daily biological tests performed on sterilizers and do records show compliant test results?

J) Are sterilizer records on file for each load?

K) Are integrator tests on file for each flash load and do records show compliant test results?

L) Are PM records for sterilizers current and is equipment in good condition?

M) Is there a current list of scope in SPD?

N) Are scopes stored per policy? Clean area and 6in off the ground or in a cabinet

M) Are PM records for sterilizers current and is equipment in good condition?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

UTILITY MANAGEMENT

Are emergency power outlets:

A) Clearly marked by red covers and outlets?

B) Being used for critical equipment only?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Electrical panels and devices:

A) Are breakers in distribution panels labeled?

B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

C) Are all covers free from damage, securely in place?

D) Are waiting rooms provided with tamper-resistant outlets?

E) In the area free of extension cords and multi plug-in outlet strips? (Patient care area only )

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are medical gas zone and main valves:

A) Marked to identify the area served?

B) Are the valves accessible for immediate access? And not blocked?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Are plumbing systems:

A) Autoclaves free of leaks from supply, drain or splashing?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Temperature and humidity:

A) Is temperature and humidity monitored in each OR and areas where anesthetic gases are administered?

B) Are temperatures maintained between 68 and 73 degrees?

C) Are relative humidity levels maintained between 35 and 60 percent?

D) Have appropriate actions been documented when readings are outside of parameters?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

Area pressures:

A) Are all of the OR positive pressure to corridors?

B) Is the SPD clean storage positive pressure to the corridor?

C) Is the scope storage area positive pressure to adjoining rooms and or corridor?

Have appropriate actions been documented when readings are outside of parameters?

SECURITY MANAGEMENT

SECURITY

A) Are all employees wearing identification badges in plain view?

B) Are all computer rooms locked except to essential personnel?

C) Are all computers that are not in use - logged out?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

EMERGENCY MANAGEMENT

EOP

A) Is the department emergency lighting box locked?

B) Are the Emergency Procedures flip charts easily accessible?

Deficiency

Responsible Person for Addressing Deficiency:

Date Corrected:

HAZARDOUS AREAS - (LS 19.3.5.4)

Soiled Utility Rooms and Storage Rooms >50 Square Feet (Example 5X10)

A) Clean, neat and orderly?

B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?

C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

D) Do doors to Hazardous Areas have automatic closers?

E) Do doors to corridors and rated rooms positively latch?

Deficiency

Responsible Person for Addressing Deficiency:

STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)

Staff Member Job Title:

FIRE SAFETY MANAGEMENT

A) What does R.A.C.E stand for? Rescue, Alarm, Confine, Extinguish or Evacuate

B) How do you alert everyone that there is a fire? Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box

C) When was your last time you participate in a OR fire drill and or training. (Should be annually)

SAFETY MANAGEMENT

A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill or PAPR)

C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)

D) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC Safety Manual link)

HAZARDOUS MATERIALS & WASTE:

A) What is a MSDS? (Safety Precautions, hazards, and PPE to be used)

B) Can staff explain how to obtain MSDS information? (link on the Intranet Home Page)

C) Can staff explain the code for a large HazMat spill? (Code Orange)

MEDICAL EQUIPMENT:

A) If a piece of medical equipment fails on a patient, you should? ( Call your supervisor, remove it from service (keep all items like disposables), place an out of serviced; slip on it, complete; submit an event report to Risk Management)

B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)

C) Can staff explain emergency procedures for life-support equipment? ( Describe what they should do for various life support equipment failures).

UTILITIES:

A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? (Resp. Therapy, Charge Nurse)

SECURITY:

A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)

B) Can staff explain their role to get help with an uncontrollable person? ( Dial 6999 & have operator call a Code Strong)

D) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink.)

E) Are security measures in place for the OR and can staff explain their role in providing security for patients?

EMERGENCY MANAGEMENT:

A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

C) If a building evacuation is announced, what would you do and where is your staging area? (Should know their departments staging area. (Nursing Department s Only)

STAFF QUESTIONS: 2

Staff Member Job Title:

FIRE SAFETY MANAGEMENT

A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

B) How do you alert everyone that there is a fire? Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box

C) When was your last time you participate in a OR fire drill and or training. (Should be annually)

SAFETY MANAGEMENT

A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill or PAPR)

C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)

D) Do you know where to find a current copy of the EOC/Safety manual online?(On the Intranet Home page. Click on the EOC Safety Manual link)

HAZARDOUS MATERIALS & WASTE:

A) What is a MSDS? (Safety Precautions, hazards, and PPE to be used)

B) Can staff explain how to obtain MSDS information? (link on the Intranet Home Page)

C) Can staff explain the code for a large HazMat spill? (Code Orange)

MEDICAL EQUIPMENT:

A) If a piece of medical equipment fails on a patient, you should? Call your supervisor, remove it from service (keep all items like disposables), place an &;out of serviced; slip on it, complete; submit an event report to Risk Management

B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)

C) Can staff explain emergency procedures for life-support equipment? (Describe what they should do for various life support equipment failures.)

UTILITIES:

A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? ( Resp. Therapy, Charge Nurse )

SECURITY:

A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)

B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & have operator call a Code Strong)

C) Can staff explain where to go and what to do when a Code Pink is called? (Should know what exit their department is assigned to cover during a Code Pink.)

D) Are security measures in place for the OR and can staff explain their role in providing security for patients?

EMERGENCY MANAGEMENT:

A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

C) If a building evacuation is announced, what would you do and where is your staging area? (Should know their departments staging area. (Nursing Department s Only)

Comments/Observations

Responsible Person for Addressing Deficiency:

Date Corrected:

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